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Health law's impact on doctors remains unclear

GREENVILLE, S.C. -- At his Greenville medical practice, Dr. Lyn Hammond floats from one exam room to another in his white lab coat, perusing charts before greeting his patients and tending to their ailments.

Health law's impact on doctors remains unclear

Some fear longer waits as the nation struggles with a growing physician shortage, less face time with patients, rising costs and more burdensome paperwork.

Dr. Lyn Hammond of Pelham Family Practice says he doesn’t know what changes the Affordable Care Act will ultimately bring to his practice. He looks at an X-ray with nurse Karen Carter.(Photo: Heidi Heilbrunn, The Greenville (S.C.) News)

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AMA says U.S. will be short 130,000 physicians by 2025

Doctors say they must look to stretch resources to meet increase demand

GREENVILLE, S.C. -- At his Greenville medical practice, Dr. Lyn Hammond floats from one exam room to another in his white lab coat, perusing charts before greeting his patients and tending to their ailments.

In his nearly three decades as a doctor, the family physician has seen many changes in the practice of medicine, from the increasing influence of the insurance industry over treatment decisions to the growth in hospital employment of doctors.

None is likely to be as far-reaching as the Affordable Care Act, though. It requires that most Americans have insurance by Jan. 1 or pay a penalty. And that means millions more Americans will have coverage and seek medical care.

But Hammond is uneasy about what the ACA, also known as "Obamacare," will mean for him.

"We don't really know what the impact's going to be," Hammond said.

Other physicians feel the same way.

"A significant number of people, unfortunately, are looking for an opportunity to purchase insurance," said Dr. Bruce Snyder, president of the South Carolina Medical Association. "But it's unclear to any of us how many individuals will sign up."

While many look to a day when more Americans can access health care, some also fear longer waits to see a doctor as the nation struggles with a growing physician shortage, less face time with patients, rising costs and more burdensome paperwork.

The Congressional Budget Office projects there will be 11 million newly insured Americans in 2014 and 24 million by 2016, according to the RAND Corp.

At the same time, the American Medical Association says the U.S. will be short 130,000 physicians across all specialties by 2025.

"When you get past everybody's particular political opinions about the ACA, really the question does boil down to one of volume and access," said Dr. Christopher Goodman, a Columbia internist. "And the burden falls more on primary care, internal medicine and family medicine."

Despite a concerted effort in recent years to produce more doctors, and especially primary-care physicians, there will be an acute shortage in the short term, said Dr. Albert Osbahr, a family physician in North Carolina and an AMA board member.

"We will probably see a little time before we see volume start to pick up," he said. "But as you have more volume ... it will impact how much time you spend with physicians."

The experience in Massachusetts, where a similar law took effect in 2006, showed that there were increased waits for physician services, said Stuart Guterman, a vice president at the Commonwealth Fund, a nonpartisan health policy think tank in Washington.

But Goodman said there was no evidence that the increase resulted in worse outcomes.

Guterman said there are ways to stretch resources by using other health care personnel to provide primary care under the direction of a physician to reduce some of that impact.

"In the long run, we want to see more primary-care providers available," he said. "That doesn't have to be restricted to physicians."

Osbahr said the system will have to become more efficient. For example, he said, physicians can shift more administrative duties to other staff. If there are longer waits to get appointments, maybe a better approach to scheduling needs to be devised, he added.

"I don't think physicians want to lose quality time with patients," he said. "We are going through the growing pains of making change. And we're hoping the inefficiencies of transition will slowly work their way out."

Osbahr said similar complaints were lodged as Medicare was rolled out. But now it works well and the elderly, who didn't have coverage before, are insured, he said.

Streamlining the system — by eliminating the hourlong waits to get approval for a test or medication or having to submit bills repeatedly, for instance — will increase the number of patients who can be seen, the doctors said.

Medical teams need to learn how to work smarter, not harder, said Reid Blackwelder, president of the American Academy of Family Physicians.

"If we use our electronic systems better, our teams better ... we can focus on one or two issues that are very important," he said, "and decrease waiting times and improve the quality of time we have."

In addition, there will be fewer newly insured patients in states like South Carolina that didn't expanded their Medicaid programs, said Alwyn Cassil of the Center for Studying Health System Change, a nonpartisan think tank in Washington, D.C.

About 200,000 South Carolinians who would have been eligible for Medicaid — and therefore may have added to the newly insured population — won't have that coverage.

Furthermore, Cassil said, all newly insured patients won't show up on day one.

Hammond said he's not convinced there will be a big influx of newly insured patients anyway. Some people still won't be able to afford coverage, and some young, healthy people just won't buy it, he said.

On the plus side, the ACA does direct some funds to expand the pool of primary-care doctors, Goodman said.

But Snyder said more needs to be done to meet the growing demand.

"We are now beginning to have more reimbursement for primary care, encouragement for young medical students to go into primary care," he said.

"But I don't think we will be able to produce enough physicians. We need to retain physicians in practice and make primary-care practice more appealing to them. We would like to see more money go into primary-care incentive programs."

The ACA provides bonuses to primary-care doctors and raises the Medicaid reimbursement to the Medicare level, Blackwelder said.

"On average, Medicaid pays about two-thirds of Medicare," he said. "So right off the bat, physicians will get additional money for those patients."

Cassil added that doctors who've been seeing uninsured patients should now get paid for those patients, if they enroll in Medicaid or Obamacare.

"For some practices who have been providing charity care to uninsured patients who get covered, they will be getting paid something," she said.

The AMA supports most of the elements of Obamacare, including expanded insurance coverage, elimination of pre-existing condition exclusions and lifetime caps, and extending coverage to young adults through their parents' insurance, Osbahr said.

But it would like to see more done about tort reform, the removal of the Independent Payment Advisory Board, which was tasked under the ACA with finding savings in Medicare without reducing coverage or quality, and reducing onerous documentation requirements.

"Reasonable people can disagree about how we go about improving access to care or controlling costs," Goodman said. "But if you look through a summary of everything the ACA does, there are only a few parts that are controversial."